Ten minutes after a vancomycin infusion begins, a client dev… | MyMerci
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Adverse Effects/Contraindications/InteractionsPPT
Question
Ten minutes after a vancomycin infusion begins, a client develops flushing, itching, and erythema of the neck and upper chest. What should the nurse do first?
1Stop the infusion and assess the client's airway and vital signs.✓ Correct answer
2Slow the infusion rate and continue to monitor the client's symptoms.
3Administer diphenhydramine as prescribed and restart the infusion.
4Notify the healthcare provider immediately and prepare for intubation.
Explanation
Flushing, itching, and erythema of the neck and upper chest shortly after vancomycin begins suggest a vancomycin infusion reaction. The nurse should first stop the infusion and assess the client's airway, breathing, circulation, and vital signs (option 1). After assessment, follow the reaction protocol and provider orders; treatment may include an antihistamine and, once symptoms resolve, a slower infusion for future dosing. Continuing or restarting the infusion before assessment is unsafe. Escalate airway management immediately if signs of anaphylaxis or respiratory compromise appear.
Clinical Judgment Use the client cues, timing, labs, and safety risks to select the response that best fits Vancomycin infusion reaction.
Memory Tip Match the strongest cue cluster to the safest nursing judgment.
KR vs US NCLEX items reward cue-based priority thinking rather than isolated recall.
Clinical scenario
Clinical Practice Guide For Vancomycin infusion reaction, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.
Caution Do not choose an action from one isolated cue when the full scenario changes priority or safety.
Key concepts
Vancomycin — An antibiotic used for serious gram-positive infections.
Infusion Reaction — A reaction related to medication administration rate or exposure.
Erythema — Redness of the skin caused by increased blood flow or irritation.